A new report about pregnancy-related deaths in the United States suggests that the solution to the country’s maternal mortality problem lies far beyond the hospital delivery room, where most media attention and health interventions have been focused in the past several years.
The report from the U.S. Centers for Disease Control and Prevention (CDC), published Tuesday, analyzes time of death and cause of death of pregnant women and new mothers for the first time. It found that maternal deaths are split about evenly into three distinct time frames: pregnancy, the day and week of childbirth, and up to one year after birth. The leading causes of maternal death varied greatly depending on the time period.
The new analysis also determined that about 60% of all maternal deaths could have been prevented — a statistic that held true for all races. However, black and Native American women still die from pregnancy-related complications at a rate that’s about three times higher than white women.
Taken together, these new data points suggest that nonmedical factors, like housing, food insecurity, or a lack of medical coverage, can contribute to a new mother’s death and should be part of any proposed solution to tackle perinatal deaths in the United States.
Pregnancy-related deaths in the United States have been steadily rising since the CDC began tracking them in 1986. The rate was 7.2 deaths per 100,000 live births in 1987. In 2015 (the most recent year data is available), that number was 17.2 deaths per 100,000 live births.
This figure encompasses all deaths from pregnancy-related complications up to one year after birth. It isn’t directly comparable to rates of maternal mortality worldwide, because other countries tend to count maternal deaths according to the World Health Organization’s definition — as occurring either during pregnancy or within six weeks after the end of the pregnancy.
The United States still stands out among developed countries when it comes to deaths among new or expectant mothers. While other countries have managed to drive this number down, the United States has not, making it one of the most dangerous places in the developed world to give birth.
To learn more about how different pregnancy and postpartum recovery time frames pose different risks to women, CDC researchers analyzed data from the national Pregnancy Mortality Surveillance System, which captured 3,410 maternal deaths spanning 2011 to 2015.
They found that among the 2,990 women for which there was data available about the time of their death, about 31% died during pregnancy, and cardiovascular conditions were among the leading causes of death. About 36% died either on the day they gave birth or less than a week afterward, when the leading causes of death were hemorrhage, amniotic fluid embolism, preeclampsia, and infection. The remaining 33% died up to one year after giving birth, when the leading cause was heart disease.
“If you look at the timeline of these deaths, you can see how important continued care over that 365 days would be.”
The share of deaths that occur up to a year after birth underscores the importance of insurance, says Lisa Hollier, MD, MPH, past president of the American College of Obstetricians and Gynecologists. As it stands, low-income women who qualify for Medicaid when they become pregnant often end up losing that coverage 60 days after they give birth, especially if they live in a state that chose not to expand Medicaid.
“If you look at the timeline of these deaths, you can see how important continued care over that 365 days would be,” Hollier says.
In addition to more health insurance coverage, the CDC report also suggests a list of wide-ranging community and state-level strategies to prevent future deaths. They include everything from improving access to healthy foods to prioritizing new and expectant mothers for temporary housing programs to improving transportation to expanding Medicaid coverage and the clinics that take this kind of insurance. Patricia Suplee, PhD, an obstetric nurse and associate professor at Rutgers University Camden, says she hopes the list will help organizations and doctors come up with new policies that can help drive down deaths. “Prior to being discharged, all women should receive education on potential warning signs of postpartum complications, especially since more than 50% of deaths occur during this time frame,” she says.
The report also analyzed maternal death data from 13 different states that had maternal mortality review committees. These committees are charged with analyzing each maternal death and trying to figure out if it could have been prevented at the community, health facility, patient, provider, and system levels.
The CDC found that from 2013 to 2017, 60% of deaths could have been prevented — a number that has been previously reported. The surprise, though, was that this number didn’t differ significantly by racial group. Among white women, 62.7% of deaths could have been prevented. For black women, that number was 57.4%, and for Hispanic women, this number was 58.3%.
The review committees also found that there were no significant differences by race when it came to the level of factors that were implicated in maternal deaths, says Emily Petersen, MD, an OB-GYN and co-author of the CDC report. However, there wasn’t enough data to analyze individual contributing factors by race.
“We saw that multiple factors contributed to each of the deaths,” Petersen says. “The data really do demonstrate that there is often more than one factor at play in these deaths.”
But just because contributing factors appear to be evenly distributed by category, this doesn’t discount the growing body of research about the role that structural racism and implicit bias play in pregnancy-related deaths, says Rear Admiral Wanda Barfield, MD, MPH, director of the Division of Reproductive Health and assistant surgeon general in the U.S. Public Health Service.
In a press conference to discuss the CDC’s findings, Barfield nodded at studies showing, among other things, that black women are more likely to give birth in low-quality hospitals and have pregnancy-complicating chronic conditions like hypertension and cardiovascular disease, and that the racial disparity in maternal deaths persists even when black women are highly educated. Personal stories were also a powerful source of anecdotal evidence.
“What we’ve seen, at least from the stories women have told, is that many [black women] have said they’re not being heard in terms of their concerns or conditions around the pregnancy and postpartum period,” Barfield says.
Maternal deaths in the United States recently became the subject of renewed interest thanks in part to high-profile media projects like NPR’s Lost Mothers series in 2017, which sought to match a face, name, and story with each statistic.
The coverage inspired others to investigate the causes of maternal mortality in the United States and attracted politicians’ attention, with the focus being mostly on how to improve hospital protocols for high-risk pregnancies.
A raft of new federal bills address the issue directly and propose policies that would award more money to states that want to set up quality care collaboratives, improve hospital practices, or experiment with innovative new case management strategies for the women at highest risk of a dangerous birth.
The subject has also become an issue in the 2020 presidential race, as three of those bills have been proposed by Democratic nominee hopefuls Sen. Kamala Harris (D-Calif.), Sen. Kirsten Gillibrand (D-N.Y.), and Sen. Cory Booker (D-N.J.).
“The social and environmental context in which women live do tend to impact their health,” says Nicole Davis, MPH, PhD, another co-author of the report and an epidemiologist with the CDC. “The hope is that our public health and prevention colleagues at the local level can help to translate these findings into effective policies and programs that match the context of their own local situation.”
While this renewed attention is encouraging, pregnancy-related deaths are just a subset of the rising mortality among all women of reproductive age in the United States, says Elliott Main, MD, medical director of the California Maternal Quality Care Collaborative and an expert on perinatal care. Deaths may be rising in part due to a complex mix of increasing chronic illnesses and lack of health care coverage.
“I would caution to say that we would hope that health care for women isn’t defined by whether they’re pregnant or not,” Main says. “However, this is an opportunity to really examine health care for women and health care for pregnant women, and we shouldn’t pass it up.”